Questionnaire to Evaluate Behaviors of Old DogsClient Name* First Last Pet's Name*This section of the history form is to be completed only if your dog is older (> 7 years for larger dogs and > 10 years for smaller ones) so that we can assess changes associated with aging. If your dog is not elderly or you have no complaints that could be associated with age, you do not have to complete this form. If you are uncertain, please complete the form.1. Locomotory/ambulatory assessment (select only one)No alterations or debilities notedModest slowness associated with change from youth to adultModerate slowness associated with geriatric agingModerate slowness associated with geriatric aging plus alteration or debility in gaitModerate slowness associated with geriatric aging plus some loss of function (e.g., cannot climb stairs)Severe slowness associated with extreme loss of function, particularly on slick surfaces (may need to be carried)Severe slowness, extreme loss of function, and decreased willingness or interest in locomoting (spends most of time in bed)Paralyzed or refuses to move2. Appetite assessment (may select more than one)No alterations in appetiteChange in ability to physically handle foodChange in ability to retain food (vomits or regurgitates)Change in ability to find foodChange in interest in food (may have to do with their ability to smell)Change in rate of eatingChange in completion of eatingChange in timing of eatingChange in preferred textures3. Assessment of elimination frequency and “accidents” (select only one)No change in frequency and no "accidents"Increased frequency, no "accidents"Decreased frequency, no "accidents"Increased frequency with "accidents"Decreased frequency with "accidents"No change in frequency, but "accidents"4. Assessment of Bladder Control (select only one)Leaks urine when asleep, onlyLeaks urine when awake, onlyLeaks urine when awake or asleepFull-stream, uncontrolled urination when asleep, onlyFull-stream, uncontrolled urination when awake, onlyFull-stream, uncontrolled urination when awake or asleepNo leakage or uncontrolled urination, all urination controlled, but in inappropriate or undesirable locationNo change in urination control or behavior5. Assessment of Bowel Control (select appropriate answer if this occurs)Defecates when asleep Formed Stool Diarrhea MixedDefecates without apparent awareness Formed Stool Diarrhea MixedDefecates when awake but undesirable or inappropriate areas Formed Stool Diarrhea MixedNo changes in bowel control No changes in bowel control6. Visual acuity-how well do you think the dog sees? (select only one)No change in visual acuity detected – appears to see as well as everSome change in acuity not dependent on ambient light conditionsSome change in acuity dependent on ambient light conditionsExtreme change in acuity not dependent on ambient light conditionsExtreme change in acuity dependent on ambient light conditionsBlind7. Auditory acuity-how well do you think the dog hears? (select only one)No apparent change in auditory acuitySome decrement in hearing-not responding to sounds to which the dog used to respondExtreme decrement in hearing-have to make sure the dog is paying attention or repeat signals or go get the dog when calledDeaf-no response to sounds of any kind8. Play interactions-if the dog plays with toys (other pets are addressed later), which situation best describes that play? (select only one)No change in play with toysSlightly decreased interest in toys, onlySlightly decreased ability to play with toys, onlySlightly decreased interest and ability to play with toysExtreme decreased interest in toys, onlyExtreme decreased ability to play with toys, onlyExtreme decreased interest and ability to play with toys9. Interactions with humans-which situation best describes that interaction? (select only one)No change in interaction with peopleRecognizes people but slightly decreased frequency of interactionRecognizes people but greatly decreased frequency of interactionWithdrawal but recognizes peopleDoes not recognize people10. Interactions with other pets- which situation best describes that interaction? (select only one)No change in interaction with other petsRecognizes other pets but slightly decreased frequency of interactionRecognizes other pets but greatly decreased frequency of interactionWithdrawal but recognizes other petsDoes not recognize other petsNo other pets or animal companions in house or social environment11. Changes in sleep/wake cycle (select only one)No changes in sleep patternsSleeps more in day, onlySome change-awakens at night and sleeps more in dayMuch change-profoundly erratic nocturnal pattern and irregular daytime patternSleeps virtually all day, awake occasionally at nightSleeps almost around the clock12. Is there anything else you think we should know?
